TexasAIM Sepsis Enrollment Form | Texas Department of State Health Services (DSHS)

TexasAIM Sepsis in Obstetric Care Enrollment and Team Participation Form

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Enrollment in the TexasAIM Sepsis Learning Collaborative is open through February 28, 2025. To enroll in TexasAIM, your team must complete this online enrollment form and email us a signed Sepsis CEO Agreement Form. Use this enrollment form to:

Enroll your hospital in the TexasAIM Sepsis in Obstetric Care at the Basic or Plus level.
Change your hospital's participation level from Basic to Plus or vice versa; or
Let us know about changes to your CEO.

Please review the TexasAIM Sepsis in Obstetric Care Enrollment Packet, Guidance on Team Formation, and CEO Agreement to Participate documents here for more details:  https://tinyurl.com/TexasAIMSepsisEnroll

If you have any questions, please email us at TexasAIM@dshs.texas.gov.

Name of Person Completing the Enrollment Form:

First Name

Last Name

Credentials

Job Title

Phone Number
(Use format 555-555-5555)

Opt-Out of Contact Information Sharing within TexasAIM Sepsis in Obstetric Care

Your hospital team's contact information will be used by the TexasAIM DSHS Operations Team and shared with other teams in the collaborative. If you do not wish for your team's contact information be shared with the other teams in the collaborative, check this box here.

Opt-Out of Contact Information Sharing